European Journal of Case Reports in Internal Medicine <p>The <strong>European Journal of Case Reports in Internal Medicine</strong> is an official journal of the European Federation of Internal Medicine (EFIM). The journal wants to promote the practice of internal medicine in Europe. Its aim is to provide a forum to internal medicine doctors.<br> <strong>EJCRIM</strong> welcomes papers describing unusual or complex cases and case series that an internist may encounter in everyday practice. Case series are also welcomed as long as they demonstrate the appropiateness of a therapeutical approach or unusual manifestation of a disease.<br> The journal would also consider brief reasoned reports of issues relevant to the practice of Internal Medicine, as well as Abstracts submitted to scientific meetings of European societies of Internal Medicine.<br> <strong>EJCRIM</strong> utilizes the CNR-SOLAR system to permanently archive the journal for purposes of preservation, reservation and research and it is also indexed on Google Scholar and DOAJ. We encourage the use of Kudos to maximize the article's visibility.<br> <strong>EJCRIM</strong> is peer-reviewed with single-blind review and freely accessible to all.</p> SMC media s.r.l. - Via Giovenale 7, Milan - Italy en-US European Journal of Case Reports in Internal Medicine 2284-2594 <h3>Copyright and Disclosures</h3> <p>Every author must sign a copyright transfer agreement and disclose any financial or professional interest in any company, product, or service mentioned in an article. This authorization includes all submitted text including illustrations, tables, and other related materials.<br> If this submission contains any <strong>material that has been previously published</strong>, this authorization <strong>must also be accompanied</strong> by all necessary Permission to Reproduce Published Material" forms completed by the current copyright owner. If this submission contains any <strong>previously unpublished material</strong> for which the person(s) signing this form <strong>does not own copyright</strong>, an additional "Authorization to Publish" form is required from each corresponding copyright owner.</p> <h3>Copyright Transfer Declaration</h3> <p>(this may be included as a word document with your manuscript submission)<br> I confirm that I am the current copyright owner of the material described above and hereby transfer and assign to the European Journal of Case Reports in Internal Medicine (EJCRIM) all copyrights in and to the material for publication throughout the world, in all forms and media, in English and in any other language(s). Such transfer includes publication in this and all future editions of the publication named above and in any other publications (including slide collections and any other nonprint media) of EJCRIM and gives EJCRIM the sole authority to grant rights for use of the material by others.<br> I waive EJCRIM from any liabilities connected to the incorrect copyright statement.<br>The copyright agreement form can be downloaded <a style="font-weight: bold;" href="/documents/EJCRIM_Copyright_auth.pdf">HERE</a> or requested to the editorial office <a style="font-weight: bold;" href=""></a></p> Non-Obstructive Middle Lobe Syndrome: An Unusual Cause of Recurrent Pneumonia in an Elderly Woman <p>An 84-year-old woman had five episodes of pneumonia in 4 months. Despite extensive comorbidities and advanced age, her health status was good and the recurrence seemed unjustified. Exhaustive background investigation revealed 14 episodes of right-sided pneumonias during the 3 previous years and an inconclusive investigation with CT of the thorax and bronchofibroscopy, despite some fibrotic and atelectasic alterations in the right middle lobe. A new right-sided x-ray showed a wedge-shaped density extending anteriorly and inferiorly from the hilum, and CT of the thorax revealed aggravated middle lobe abnormalities with thickening of the bronchial wall and segment atelectasis, without any visible airway obstruction. After extensive work-up had excluded other causes of recurrent pneumonia and immunodeficiency, a non-obstructive middle lobe syndrome (MLS) was deemed responsible for the repeated episodes of pneumonia. MLS is characterised by chronic hypoventilation and atelectasis of the middle lobe, facilitating secretion accumulation, chronic inflammation and repeated infection. After treatment with bronchodilators and immunostimulants was initiated, the patient experienced no recurrences for several months.</p> João Rua Ricardo Marques Rafael Silva Bráulio Gomes Jorge Fortuna ##submission.copyrightStatement## 2017-11-23 2017-11-23 4 8 10.12890/2017_000737 Mad Honey Disease <p>A 46-years old woman presented with acute onset of nausea, vomiting and prostration in the ER. She appeared ill and was poorly responsive to verbal stimuli. The physical examination showed a systolic blood pressure of 60 mmHg and a pulse of 40 bpm. ECG was notable for slight ST-elevations in the inferior leads. Right ventricular myocardial infarction with cardiogenic shock and bradycardia was suspected. Supportive therapy with catecholamines was initiated and a emergency coronary angiography was arranged. However, lab results showed normal troponin levels and a subsequent echocardiogram showed the absence of abnormal wall motions. By thorough history taking with the spouse it turned out that the patient had consumed a Turkish honey approximately an hour before the beginning of the symptoms. The patient made a full recovery within 24 hours with only supportive therapy. In retrospect the clinical presentation was highly indicative of poisoning with Grayanotoxins from a plant, Rhododendron, which is found as contaminant in some sorts of honey in the Black Sea area. A pollen analysis confirmed the presence of Rhododendron in a honey sample.&nbsp; Historically this poisoning is mentioned over the millennia as mad honey disease. The ST-elevations in the ECG were a sign of early repolarization, a non-pathological finding.&nbsp;&nbsp;</p> Laurentiu Broscaru Claudiu Dobre Frederik Rösick Arnela Halilovic Dietrich Gulba ##submission.copyrightStatement## 2017-11-20 2017-11-20 4 8 10.12890/2017_000742 Therapeutic Challenges in the Management of Acute Pulmonary Embolism in a Cancer Patient with Chemotherapy-induced Thrombocytopenia <p>This case demonstrates the therapeutic challenges encountered when managing an acute pulmonary embolism in a cancer patient with thrombocytopenia. A 64-year-old man with a history of lung cancer receiving chemotherapy was admitted to Walsall Manor Hospital with haemodynamic instability consistent with a pulmonary embolism, proven on computed tomographic pulmonary angiogram. His platelet count was noted to be 35×10<sup>9</sup>/l (chemotherapy-induced thrombocytopenia). After discussions, he was deemed not suitable for thrombolysis based on risk versus benefits. The patient was initially transfused one adult dose of platelets and treated with half the therapeutic dose of low molecular weight heparin (LMWH). The same management plan was followed until the platelet count exceeded 50×10sup&gt;9/l, after which the patient was established on the full therapeutic dose of LMWH. Clinically, the patient improved and was discharged. Three months after discharge, follow-up revealed sustained clinical improvement while the patient continued to be on the full therapeutic dose of LMWH with a stable platelet count.</p> Abuajela Sreh Shailesh Nakeshree Senthil-Kumar Krishnasamy Nuri Alfasi ##submission.copyrightStatement## 2017-11-14 2017-11-14 4 8 10.12890/2017_000713 An Abdominal Aortic Aneurysm, Intramural Thrombus and Moderate Leak in an Asian Man Presenting with Acute Gastroenteritis <p><em>Introduction:</em> Missing a leaking abdominal aortic aneurysm (AAA) is common in medical practice because few at-risk patients have a history of AAA and many have an unusual presentation.<br> <em>Background:</em> AAA is less common among Asians than white Caucasians of the same age. Our patient had no significant risk factors apart from age and sex and had an unusual presentation. <br> <em>Patient and Methods:</em> A 67-year-old Asian man presented to the emergency room (ER) with a 1-day history of nausea, vomiting, diarrhoea, fever and abdominal pain. He was febrile, dehydrated. and had marked tenderness at the right iliac fossa. Laboratory findings suggested bacterial gastroenteritis but this did not explain the localized tenderness at the right iliac fossa.<br> <em>Result and Discussion:</em> A CT scan of the abdomen revealed an AAA arising above the origins of the renal arteries, an intramural thrombus, a retroperitoneal haematoma and a leak extending to the right iliac fossa. The patient was transferred to another hospital and underwent exploratory laparotomy, surgical repair of the aneurysm, and aortobi-iliac grafting with removal of the thrombus. The patient was discharged in good shape 3 weeks after surgery. Without the CT scan of the abdomen, the AAA could have been missed and the patient treated for severe gastroenteritis.</p> Abdalla Khalil Mohammed Bafaraj Badr Badr Majduldeen Azzo Ahmed Sabry ##submission.copyrightStatement## 2017-11-09 2017-11-09 4 8 10.12890/2017_000759 Tuberculous Tonsillitis in a Patient Treated with an Anti-TNF Ag <p>Tuberculosis remains a concern in patients receiving anti-TNF therapy as these individuals have a higher incidence of extrapulmonary and disseminated tuberculosis. Tuberculous tonsillitis is an unusual presentation of extrapulmonary tuberculosis, which is diagnosed mostly in immunodeficient patients. We report the case of a 33-year-old woman, diagnosed with Behçet’s syndrome, immunosuppressed with adalimumab, cyclosporine and prednisolone. She had odynophagia for 2 weeks, fever and a hypertrophied, ulcerated left tonsil. A tonsil biopsy revealed a granulomatous inflammatory process. Ziehl-Neelsen staining was positive for acid-fast bacilli. The chest x-ray revealed a milliary pattern. Gastric juice was positive for <em>Mycobacterium tuberculosis</em> complex DNA. A diagnosis of tonsillar and pulmonary tuberculosis was established. This case report highlights the low threshold for a tuberculosis diagnosis in unusual locations in patients treated with anti-TNF therapy. </p> Sara Ferreira Paula Vaz-Marques ##submission.copyrightStatement## 2017-10-30 2017-10-30 4 8 10.12890/2017_000690 Raynaud's of the Tongue <p>We describe a 40-year-old lady who presents with a painful white tongue on exposure to the cold. The differential diagnosis and investigations are outlined with a discussion about this unusual presentation of a common problem.</p> Martin Edward Perry Shazmeen Surtee Zainab Nawaz ##submission.copyrightStatement## 2017-10-30 2017-10-30 4 8 10.12890/2017_000689 Spondylodiscitis with Epidural and Psoas Muscle Abscesses as Complications After Transrectal Ultrasound-guided Prostate Biopsy: Report of a Rare Case <p>A 71-year-old man presented with spondylodiscitis with epidural and psoas muscle abscesses following transrectal ultrasound (TRUS)-guided prostate biopsy. These rare complications were detected by computed tomography of the abdomen and magnetic resonance imaging of the lumbar spine. The patient was successfully treated with antibiotics and underwent neurosurgery. Awareness of presentations such as backache and weakness of the lower limbs after prostate biopsy is important as these symptoms are usually mistaken for bone or muscle problems and often not recognized as being related to infection.</p> Chiao-Ching Li Chiao-Zhu Li Sheng-Tang Wu Tai-Lung Cha Shou-Hung Tang ##submission.copyrightStatement## 2017-10-30 2017-10-30 4 8 10.12890/2017_000694 Goodpasture’s Syndrome with Negative Anti-glomerular Basement Membrane Antibodies <p>A young male patient with rapidly progressive and life-threatening pulmonary haemorrhage due to anti-glomerular basement membrane (anti-GBM) antibody disease without renal involvement repeatedly tested negative for serum anti-GBM antibodies. Although rare, anti-GBM antibody disease should be considered in the differential diagnosis in patients with life-threatening pulmonary haemorrhage due to isolated diffuse alveolar haemorrhage. Enzyme-linked-immunosorbent assay (ELISA) testing for anti-GBM antibodies in anti-GBM antibody disease can give false-negative results. A negative serum anti-GBM antibody test is therefore insufficient to exclude the diagnosis. Thus, a kidney or lung biopsy should be considered in any case with a high clinical suspicion but negative anti-GBM antibody test to confirm or rule out the diagnosis.</p> Tjitske Berends-De Vries Susan Boerma Joan Doornabal Bert Dikkeschei Coen Stegeman Thiemo Veneman ##submission.copyrightStatement## 2017-10-30 2017-10-30 4 8 10.12890/2017_000687 ANCA-negative Granulomatosis with Polyangiitis: A Difficult Diagnosis <p>Granulomatosis with polyangitiis (GPA) is a systemic small and medium vessel vasculitis, commonly associated with anti-neutrophil cytoplasmic antibodies (ANCAs). Presenting signs and symptoms in GPA are varied and patients may present with constitutional, non-specific symptoms, which can delay the diagnosis. Tissue biopsy of the site of active disease can confirm the diagnosis of GPA, in which necrotising granulomatous inflammation is seen. However, surrogate markers may be used for diagnosis without a tissue biopsy. They include upper and lower airway symptoms, signs of glomerulonephritis and a positive ANCA. However, approximately 10–20% of patients with GPA are ANCA negative, allowing for the diagnosis to be overlooked, particularly in those patients with non-specific findings. The reason for the absence of ANCAs is unclear.</p> Eilis McCarthy Muneeb Mustafa Mike Watts ##submission.copyrightStatement## 2017-10-30 2017-10-30 4 8 10.12890/2017_000625 Misleading Serum Procalcitonin Elevation in Heatstroke <p>A healthy 44-year-old man, with a typical presentation of exertional heatstroke, presented with an increase in serum procalcitonin (PCT) levels. Suspecting a coexisting infection, the emergency physician started empirical antibiotic treatment and obtained samples for culture. The antibiotic treatment was stopped immediately after ward admission due to lack of signs of infection. The patient recovered completely after several days of rehydrating therapy and cultures remained negative for bacterial growth. PCT elevation is typically found with heatstroke, but this association is rarely found in daily practice due to the futility of PCT testing in this situation. Increased serum PCT levels in the context of heatstroke must not lead to an unsupported alternative diagnosis and useless investigations, tests and treatment.</p> Marco Enzo Tau Melissa Cocca ##submission.copyrightStatement## 2017-10-30 2017-10-30 4 8 10.12890/2017_000695